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University of Rochester Director of Regulatory Compliance, Risk Management, and Quality Improvement, Department of Psychiatry - 233077 in Rochester, New York

Director of Regulatory Compliance, Risk Management, and Quality Improvement, Department of Psychiatry Job ID 233077

Location Strong Memorial Hospital Full/Part Time Full-Time Favorite Job Regular/Temporary Regular Opening

Full Time 40 hours Grade 055 Psychiatry Quality Assurance


8 AM-5 PM


General Purpose:

Functions as a key member of the department’s senior leadership team with broad responsibilities across all of the behavioral health programs, including CPEP, inpatient ambulatory, partial hospitals etc., relevant to regulatory compliance with accreditation, state agency regulations, patient events, risk management, and quality data reporting and quality performance improvement . Directs Psychiatry’s compliance with regulatory and accreditation requirements for operating clinical services, components of which include ongoing monitoring and evaluation of patient care, incident reporting/review, risk management, safety management, and education processes. Reporting directly to Senior Program Administrator, acts as department Quality Assurance Liaison to the Hospital Quality office, in tandem with Medical QAL. Provides oversight to ensure that the department meets the hospital and external regulatory requirements of patient events management, special investigations, incident review, program level review including patient complaint and grievance. In collaboration with Strong Memorial Hospital’s Quality Assurance, Patient Relations, Office of Counsel/Risk Management and senior leadership teams, directs the department in the resolution of psychiatric quality improvement and related patient event or outcomes. Ensures compliance with regulatory requirements for monitoring, evaluation, and documentation of care rendered and in the resolution of psychiatry related quality issues at the highest levels internally and externally. Represents the Department of Psychiatry in meeting the mandates of quality and risk components of regulatory and accrediting agencies including but not limited to NYS Justice Center, Office of Mental Health (OMH), Office of Alcohol and Substance Abuse Services (OASAS), Joint Commission, NYS Department of Health (DOH).

Specific Responsibilities:

20% Develops, implements and directs mechanisms to support compliance with regulatory and accreditation requirements for operating clinical services. Actively engages with programs during external agency certification visits including but not limited to: Joint Commission, OMH, OASAS, and Disability Rights NY.

Interprets and disseminates information within the Department and at the hospital level concerning standards, regulations, final rule and policies of all certification and accreditation agencies which affect Psychiatry’s programs. Leads in the development of Performance Improvement Plans and Corrective Action Plans associated with citations during certification, and recertification processes in collaboration with clinical program directors. Provides education regarding changes and ongoing resource support as subject matter expert for inquiries regarding changes in regulations or guidance from certifying or accreditation agencies across the department

20% Acts as Department of Psychiatry Quality Assurance Liaison to the Medical Center Quality Office and hospital board. This includes overseeing psychiatry Root Cause Analysis and teams assembled to perform RCA, with hospital level report out. Represents department in collaboration with main hospital Quality Office in quality related events and complaints that rise to Joint Commission, OMH, DOH investigations, on premises or correspondent inquiry.

20% Directs the department’s Assistant Quality Officer (Risk Management/Grievance Coordination), Project Nurse for Regulatory Compliance monitoring and Information Analyst. Provides direction and oversight of investigations and responses to inquiries from external agencies which relate to quality assurance in Psychiatry. This includes oversight of RL Solutions incident management system and reports to NIMIRS. Oversight and direction for follow ups and associated operations implementations with monitoring for sustained improvement. Attends and participates in reviews of serious incidents assigns SOC and recommendations for improvement.

20% Plans the agenda, presentations, and co-chairs with the Quality Medical Officer, the Department Quality Steering Committee in which QAPI implementation and monitoring, quality improvement aggregate data is disseminated and acted upon, reporting, department wide quality metrics and program presentations, policy making and approvals occur. Makes recommendations for clinical operations, clinical workflows, education as it relates to incident trends and outcomes management. Monitors quality triggered Focused Professional Practice Evaluation for faculty where standard of care is not met Directs implementation of SMH Quality Plan in collaboration with department leadership and SMH Quality Office, to ensure that internal and external requirements for documenting quality efforts and improvement metrics are met. Provides oversight in ensuring that Program Directors and other appropriate principals follow up on recommended metric and actions.

10% Chairs departmental Incident Review Committee which includes facilitating committee review of IRC investigations, outcomes and standard of care assessments. This includes high-risk events and sentinel events with highly regulated internal and external reporting and corrective action planning (CAPS).

10% Acts as main contact for NYS Justice Center and regarding inquiry around patient events, allegations of abuse and neglect and other levels of review, including necessary follow up for substantiated allegations of abuse and neglect, special investigation report follow up for corrective action plans that are approved or require changes/additions.

Responds to high level patient complaints when the need arises for senior leadership response direct to complainant. Collaborates with OCMC on matters that rise to allegations of abuse and/or substantial risk level of harm.


Master’s Degree in related field and 3-5 years of experience in leadership roles and/or quality improvement in a health care setting. Knowledge of Regulatory oversite of behavioral health clinical services in NYS. Excellent organizational and communication skills. Dynamic, engaging approach to teamwork and collaboration with Sr. Hospital, Department, outside regulatory agencies and department clinical leadership.

NOTE: This document describes typical duties and responsibilities and is not intended to limit management from assigning other work as required.

How To Apply

All applicants must apply online.

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